Expect the Unexpected: The Lethal Potential of Disease

Scenario 1: A 62 year-old man with a history of hypertension, hyperlipidemia, coronary artery disease, a remote myocardial infarct, and a triple coronary artery bypass grafting procedure performed 10 years ago has a witnessed collapse at home. Assessment by medical first responders reveals absence of vital signs and the man is pronounced dead by the medical control physician.  According to his spouse, he takes his medications as prescribed and has had no recent health complaints. He was last seen by his internist and cardiologist within the preceding 12 months with no new health problems found.  His history is negative for psychiatric illness, substance use disorder, or injury of significance.

Police are in attendance and report the death to the local Medical Examiner’s Office. A death investigator from the office responds to the death scene and finds no signs of foul play or trauma, drugs of abuse, or prescription medication discrepancies. Contact information for the decedent’s internist is found in his wallet and the physician is called and briefed on his patient’s death and the benign death circumstances.  The death investigator asks if the physician is willing to sign the death certificate, to which he replies: “I will not sign the death certificate because I don’t know why he died and I did not attend the death.”

Scenario 2: A 62 year-old man with a history of hypertension, hyperlipidemia, coronary artery disease, a remote myocardial infarct, and a triple coronary artery bypass grafting procedure performed 10 years ago has a witnessed collapse at home. Assessment by medical first responders reveals an unresponsive, breathing man in ventricular fibrillation. Resuscitative efforts are promptly initiated and continued en route to the hospital and continued further by emergency room medical personnel. Despite all efforts, the man expires and is pronounced dead by the emergency physician 40 minutes after arrival. No signs of trauma are found. According to his spouse, he takes his medications as prescribed and has had no recent health complaints. He was last seen by his internist and cardiologist within the preceding 12 months with no new health problems found. His history is negative for psychiatric illness, substance use disorder, or injury of significance.

The emergency physician reports the death to the local Medical Examiner’s Office along with the decedent’s medical history and contact information for his internist and cardiologist obtained from the electronic medical record. The death investigator taking the report of death asks the emergency physician if he is willing to sign the death certificate, to which he replies: “I will not sign the death certificate because I don’t know why he died and I am not his regular physician.” The investigator then contacts the internist and asks if she is willing to sign the death certificate, to which she replies: “I will not sign the death certificate because I don’t know why he died and I did not attend the death.” In a final effort, the investigator contacts the cardiologist and asks if she is willing to sign the death certificate to which she replies: “I will not sign the death certificate because I don’t know why he died and I did not attend the death.”

Many natural diseases other than cardiovascular disease also have the potential to cause sudden decompensation and death even while under treatment.  Recognition of this will help to allay the reluctance that some physicians may have in regards to certification of sudden, unexpected natural deaths. While medical examiners or coroners often certify these types of deaths, clinicians, including emergency medicine physicians, are better equipped to certify them because chances are they either knew the patients clinically or otherwise have ready access to their medical records. In certifying the death, the clinician makes a determination based on the patient’s history and/or medical knowledge that in all probability, more likely than not, the patient died of “X”. One-hundred percent certainty is not required for this determination.

Which of the physicians, the internist, the cardiologist, or the emergency physician is qualified to certify the death? The answer is: all of them.

How would Doc4N6 certify both deaths, you ask?

Part I.

 

 

A. Sudden cardiac death

Approximate interval: Onset to death

Minutes

Due to (or as a consequence of):

B.  Remote myocardial infarct

 

Years

Due to (or as a consequence of):

C. Atherosclerotic coronary artery disease

 

Years

Due to (or as a consequence of):

D.

Part II. Other significant conditions contributing to death but not resulting in the underlying cause given in Part I  Hyperlipidemia, Hypertension
Manner of Death

Natural

 

You’ll find numerous examples of diseases and disease conditions with lethal potential and more information on who qualifies as a certifier of death in Chapters 6, 7 and 8 of Essentials of Death Reporting and Death Certification: Practical Applications for the Clinical Practitioner.

For a direct link to this book, click on: https://www.amazon.com/Essentials-Death-Reporting-Certification-Applications/dp/0998533408/ref=sr_1_1?ie=UTF8&qid=1

Stay tuned for your next dose of Practice Pearls!

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